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Home My WebLink AboutWAI2022-00084 - WAI General - 6/8/2022 13,,s01" CO S' Public r a Health Always working for a safer a healthier Mason County PO Box 1666,415 N 6th Street, Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 •:' Belfai60 (360) 75�677 ext 400 ❖ Elma: (360)482-5269 ext 400 FAX 4 . Application for Waiver/Appeal Amount Paid: q��J Receipt Number: WAIa)bd .- :2 7 Instructions 1. Complete Parts 1 and 2.No determination can be made until these parts are fully completed. 2. Fees may be billed for waivers and appeals,based on the Environmental Health Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1.Applicant/Parcel Identification Name of Applicant CTW -r D i Ain 0. C C r\ e { Telephone(3(oO)�101-00 77 J Mailing Address of Applicant 70 3 I Sf Ks(c\d i R City S tive 11-G h State W A Zip 9 M-QI y 12-digit Tax Parcel No. 2 2 0 2 S -- 7 -- 0 0 0 2 Site Address 7° 3 I S lc c fit el I. CA g d S (f 0 h M 98599 Subdivision Name and Lot Tg 2 of S VrVQ`J SiO2 PART 2: Nature of Waiver/Appeal Il Class B Reduction in Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations ❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations ❑ Contractor Certification Requirements 0 Other (Installer,Pumper,O&M Specialists) Description of Waiver/Appeal (include justification,additional material may be attached.): C N c -1 k i �cr� �j� q C C k.41 l l t Applicant Signature: Date: (p—` z;- r �� -' L+ c_ ✓LC� Revised 1/22/2015 This form may be scanned and available for public view on the Mason County Web site. Page 1 oft PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal giver o None required Class A zitlass B ❑ Class C 2. Identification of Specific Code/ Standard/Determination (include date of determination or Iatest Code/Standard revision): (rJ C- /-41 V - 101. - OT "re.A. . V 3. Nature of Appeal: (' s..et t tee_ t( �.,:.. c�Ic ye-IA-Leda sera.rt -� Ters. Fpe,t.� -}te 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director • ❑ Certified Contractor Review Board . .8'.Environmental Health Manager 5. Mitigating Factors: �.c..t'S PF''_' '} S 3334- 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: G— -- Date: LI7 9 ve7'Y PART 4: Determination of the Hearing Official Er The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted. This decision is based on the following findings and conditions: 0 The hearing official has determined that approval of this request could potentially adversely effect public health and is hereby denied. This decision is based on the following findings and conditions: Hearing Official Signature: lf7Z Date: K- Z%2— Revised 1222015 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 On-Site Sewage Systems (Chapter 246-272A WAC) Re 1 uest for Waiver From State R• lations Section L (completed by applicant) Local Health Department 1 District (2) ��ry k- (�'ghrn CO Name: (1) (see instructions V�h�r --- --- Addres—s: 7 G S I Sf k(Cad i s g d Telephone: (3(00 ) y01 00")7 Property Id-•: cation: (3) 7(Z 2 0 r S U(ve bI 0 Z Far c f I# ____ -- _-- --- -- -- Section II. (completed by applicant) WAC Requirement (5) Waiver Sought (6) V‘s WAC Number: (4) FI°�, Z 246-272A— p ��D - .4A,u,e a--t- — ;Ai" .� z Subsection: Justification(mitigation measures to be provided): (V �� Section III. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Type of Waiver: (11) [ ]Class A [.Class B [ ]Class C—Request DOH review before granting? Yes— No_ Neighbor Notification: (12) Required? Yes— No_ If needed, are agreements, easements, etc.properly filed? Yes No_ Section IV. 1 (completed by health officer) This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Site Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability to provide public health protection at least equal to that provided this chapter WAC. 1 comments,conditions and requirements oted in "ons II and III. [ ] Denied [k�-Approved/Granted—Subject c 2 f L 2 Date: Local Health Officer (13) 19 4s SON CO Irk, MASON COUNTY PUBLIC HEALTH jP. t� CLASS B WAIVER WORKSHEET �b j1c � Heal+e� • (State and Local waiver forms required)Always working for a safer healthier Mason County PO Sox 1666,415 N 6th Street,(Bldg 8)-Shelton WA,98584 Shelton:360.427-9670 ext 400 Belfalr.S60-275 4467 ext 400 p , Vao�`1 � gpPUCANT NAME 0(f 4 1 q h al C o h n- r AMERwR PERMIT NUMBER WI Q`I " v Sf. ad;a Rd rP g5ay MAILING ADDRESS Pr STATE 70 I S SITE ADDRESS CONVENTIONAL GRAVITY CONVENTIONAL PRESSURE 2 2 0 —7 S Q O Q Z O PROPOSED DRAINFIELDTYPE ❑ TAX PARCEL NUMBER S.VERTICAL SEPARATION: 1.501E SERIES: The soil series mustUp-slope vertical separation must be greater than 18"be Alderwood,Harstlne,Hoodsport, for gravity and greater than 72"for pressure. Shelton,or Sinclair Gravelly Sandy Loam. 12/ Greater than 12".............................................._................ I 0 HarAld ineG Gravelly SandyLoam...................: ❑ Greater than 18".......................................Harstine Gravelly Sandy Loam 0 0 -Determined by: �{ Hoodsport Gravelly Sandy Loam 0 "" `� ❑ Depth to hardpan..............-........._. 0 Shelton Gravelly Sandy Loam � � —••••••••••• ❑ Depth to mottling OtherSincla Gravelly Sandy Loam ❑ Both....................................................................................... Other 6.WATER TABLE LEVEL: 2.SOIL TYPE: Lest holes show evidence of z seasonal water table a types p berc nt must Send,Loamy rand,of Sandy ve restrictive layer,a curtain drain may be required Loam.Gravel percent must be less than or equal to 3 _ 0 ❑ _ -Evidence of seasonal water table: ❑ ❑ Medium Sandd ❑ CI -2,— Yes - leg :- Percent in JCS S- No Sandy Loam p -Curtain Drain required: O ❑ 0to Percent thanGra or IEt0 Yes �X �3 -Less than equal to 35% — fl No —•-•••••••••• 3 0 Greater 35% = 7.HORIZONTAL SETBACKS: C 3.SOIL DRAINAGE: F rt r0 Primary Drainfie Soils must be moderately well drained to well drained.BC ld must maintain 200'from down-gradi ent marine shorelines,surface waters,and wells. Well Drain O rt Mo yd 0 ❑ -Are increased horizontal setbacks met: Modee rately Well Drained � ❑ Other ❑ YesD 4.DRAINFIELD SLOPE: • 8.ATTENUATION ZONE Slopes must be between 3%to 30%. A 50 foot horizontal attenuation zone is required Gravity is only allowed on slopes from 3%to 15%. down-gradient of the primary drainfield. pressure is allowed on 3%to 30%. El ❑� -Is there 50 ft or greater between the down Less than 3%3%to 15% 16 W gradient side of primary drainfield and 0 property boundary: 16 Greater than 30% Ye t 30% 0 ❑ Yes ❑ property as unbuildable l'R 3 3 The 50 foot horizontal attenuation zone is required to be recorded on the deed of the operty n€N park tno dareas, approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, Proor�R�ord n� rior parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. updated Yuzols THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC NEW ON THE MASON COUNTY wEB51TE 2183334 MASON CO WA 06/17/2022 01:3B PM DELL DIANA LYNN CANNER #176279 Rec Fee: $204.50 Pages: 2 I IIIIIII II 1111 III I II I IIIIII 1II1 IIII 111II IIIII IM III I II III]Illl Return To Diana Lynn Conner 7031 SE Arcadia Rd Shelton, WA 98584 Grantor(s): (1) Diana Lynn Conner , (2) -. ' —GraTnt"ee(s):(1) PUBLIC -~ -- - __ -_ - Legal Description (1) TR 2 of Survey 8/02, SEC 28, TWP 20N, R2W (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 22028-75-00020 DECLARATION OF COVENANT FOR ON-SITE SEWAGE ATTENUATION ZONE I (We) the grantor(s) herein, am (are) the owners in fee simple of(an interest in) the • described real estate situated in Mason County, State of Washington; hereby declare this covenant&place the same on record; to wit the described real estate on which the grantor(s) owns and operates an on-site sewage disposal system which has been granted a Class B State Waiver to reduce the Minimum Vertical Separation requirements and grantor(s) is (are) required to maintain a 50-foot horizontal attenuation zone down gradient of the on-site sewage system to facilitate treatment of the sewage effluent. It is the purpose of these grants and covenants to prevent certain practices hereinafter - -- enumerated in the use of the grantor(s) land which might encumber the land set aside for further sewage treatment and disposal. NOW, THEREFORE, the grantor(s) agree(s) and covenant(s) that said grantor(s), his (her) (their) heirs, successors and assigns will not construct or install any trench, channel, ditch, road cut, utility chase, or other structure of excavation what would intercept or serve as a conduit for migrating ground water. - Dated on this 1 Li day of _ , 20 Z� Page 1 of 2 Signature of Grantor(s): (1) .la�t."_.. �frYJ�� , (2) State of Washington ) County of Mason 1, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this \IA day of S unr____ , Co\rw\ personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day d year last above written. • E.ISA M WOODARD,�'s s NOTARY PUBLIC#53326 Notary Public in and for the State of Washington, STATE OF WASHINGTON6 residing at �`51'� L � s COMMISSi EXPIRES My commission expires: cS'dam - £, AUGUST 29, 2025 s 25 Page 2 of 2